BTS Emergency oxygen audit report

Tuesday, May 10, 2016

Supply of oxygen to some NHS patients may be 'harmful' as many hospitals fail to provide written prescriptions to guide staff on its safe use or give adequate training.

One in seven patients in UK hospitals are given oxygen therapy for their condition on any given day. A new national study by the British Thoracic Society (BTS) has found that over 4 in 10 of these patients (about 6,000 on an average day) are receiving oxygen with no prescription or other written order to help ensure that staff deliver and monitor oxygen use safely and effectively.

Lung specialists are concerned that without a prescription specifying a safe ‘target range’ of oxygen levels in the body which hospital staff should monitor for and keep within, there is a real danger that patients may be given too little, or too much oxygen which can result in greater illness, and in rare cases, even death.

The BTS is using the results to call on every hospital to prescribe and document all oxygen administered to patients.

Worryingly the national audit also found that:

Over half of hospitals didn’t provide sufficient training in oxygen provision and monitoring for doctors or nurses

Even when a written prescription for oxygen was provided, 31% of patients were still getting either too little or too much oxygen. It is common to have some readings that are over and under the ‘target range’ of desirable levels of oxygen in the blood – a patient who is anxious or breathing deeply at rest can cause a rise for example. But health professionals need to monitor the situation carefully and take action as necessary

It is of special concern that 9% of patients who had been prescribed a ‘target range’ were more than 2% above it (ie they were getting too much oxygen for their condition). All of these patients had been prescribed a low ‘target range’ because they had conditions such as chronic obstructive lung disease (COPD) where too much oxygen can be harmful and may even increase the risk of death.

Hospitals, however, have shown marked improvements in many aspects of their management and delivery of oxygen to patients since the launch of the British Thoracic Society Guidelines in 2008. Studies in other countries have found similar problems and this was the world’s first national guideline for urgent oxygen use.

Encouragingly, the BTS audit reflects this progress in the UK:

85% of hospitals have implemented an oxygen policy

100% used pulse oximeters to measure a patient’s oxygen levels on all nursing observation rounds

72% recorded the patient’s oxygen levels in a dedicated oxygen section on the monitoring chart that was consistent with the BTS oxygen guidelines

The 2015 BTS Emergency Oxygen Audit analysed data from 55,208 NHS hospital patients and 7,741 (14%) were using oxygen. The study, undertaken by questionnaire between 15 August and 1 November 2015, probed the ‘state of play’ of oxygen provision in NHS hospitals.

The rationale for giving oxygen treatment in hospital is to treat low blood oxygen levels (hypoxaemia) where the body’s cells are starved of oxygen, which can cause damage to vital organs and even lead to death. Oxygen can be used to help treat a number of lung diseases – such as pneumonia or deteriorations in asthma or chronic obstructive pulmonary disease (COPD). Oxygen is also used in other diseases such as heart failure or sepsis, which can cause low blood oxygen levels.

Dr Ronan O’Driscoll, Consultant Respiratory Specialist at Salford Royal NHS Foundation Trust, who has led the British Thoracic Society’s work in this area, said:

"Oxygen is an important drug and should always be prescribed and documented in hospital like any other medication. Prescriptions and monitoring documents give us a vital record of which patients are receiving oxygen, how much they are getting and by what method. But crucially they also give a personalised ‘target range’ for each patient indicating a desirable, safe level of oxygen in the blood for hospital staff to measure for and keep within.

In a modern health service, it is concerning that so many patients in hospital are still being given this drug without any form of prescription. The situation would not be tolerated for any other drug – even a common ‘over the counter’ treatment such as paracetamol requires a prescription or other written order in hospital. Oxygen is very beneficial to many patients, but it can be harmful if misused. Therefore, it should always be prescribed or clearly documented in hospital.

In the audit, the number of patients whose oxygen levels in the blood were too high after oxygen therapy is concerning. This may be due to oxygen deficiency being seen as a much greater danger than oxygen overload - leading to a possible feeling that ‘the more oxygen we give the better.’

However, the audit showed that 44% of patients using oxygen had risk factors such as COPD that placed them at risk from excessive oxygen therapy. This needs to be addressed in staff training and we would like to see far more hospitals delivering education in this area.

We have, however, seen real improvements over the last 8 years in how NHS hospitals manage, deliver and monitor oxygen provision for patients. Nevertheless, we really must keep up the momentum for change – as improvements have largely stalled recently."

The BTS Emergency Oxygen Audit report 2015, as well as other useful resources for health professionals, can be downloaded here.

The Society won a National Patient Safety Award in 2011 for its campaigning work in this area, which has included the delivery of Guidelines, educational resources and audit to help hospitals provide oxygen safely and effectively.

The 2015 audit report can also be found in the Respiratory Futures Knowledge portal along with a wide range of legacy, current and curated respiratory assets.